How is anorexia nervosa treated?

The goals of treatment are to stabilize weight loss, begin nutrition rehabilitation to restore weight, eliminate binge eating/purging behaviors and other ritualistic eating patterns, treat emotional issues such as low self-esteem, correct distorted thinking patterns, and develop long-term behavioral changes.

Treatment options will vary depending on the individual’s needs. Treatment most often involves a combination of the following strategies:

Psychotherapy

This is a type of individual counseling that focuses on changing the thinking (cognitive therapy) and behavior (behavioral therapy) of a person with an eating disorder. Treatment includes practical techniques for developing healthy attitudes toward food and weight, as well as approaches for changing the way the person responds to difficult situations. There are several types of psychotherapy including:

  • Acceptance and Commitment Therapy. This therapy’s goal is to develop motivation to change actions rather than your thoughts and feelings.
  • Cognitive Behavioral Therapy (CBT). This therapy’s goal is to address distorted views and attitudes about weight, shape and appearance and practice behavioral modification (if “X” happens, I can do “Y” instead of “Z”).
  • Cognitive Remediation Therapy. This therapy uses reflection, and guided supervision to develop the capability of focusing on more than one thing at a time.
  • Dialectical Behavior Therapy (DBT), is CBT plus insight. In other words, this therapy helps the individual not just develop new skills to handle negative triggers, but also helps the person develop insight to recognize triggers or situations where a non-useful behavior might occur. Specific skills include building mindfulness, improving relationships through interpersonal effectiveness, managing emotions and tolerating stress.
  • Family-based Treatment (also called the Maudsley Method). This therapy involves family-based refeeding, which means putting the parents/family in charge of getting the appropriate nutritional intake consumed by the individual with the eating disorder. It is the most evidence-based method to physiologically restore health to an individual with anorexia nervosa who is under 18 years of age.
  • Interpersonal Psychotherapy. This therapy is aimed at resolving an interpersonal problem area. Improving relationships and communications, and resolving identified problems has been found to reduce eating disorder symptoms.
  • Psychodynamic Psychotherapy. This therapy involves looking at the root causes of anorexia nervosa – what are the patient’s true underlying needs and issues -- as the key to recovery.

Medication

The antipsychotic olanzapine (Zyprexa®) may be helpful for weight gain. Although there is no clear evidence that antidepressant medications can help individuals gain weight, some doctors may prescribe these drugs to help control anxiety and depression associated with an eating disorder.

Nutrition counseling

This strategy is designed to teach a healthy approach to food and weight, to help restore normal eating patterns, and to teach the importance of nutrition and a balanced diet.

Group and/or family therapy

Family support is very important to treatment success. It is important that family members understand the eating disorder and recognize its signs and symptoms. People with eating disorders might benefit from group therapy, where they can find support, and openly discuss their feelings and concerns with others who share common experiences and problems.

Hospitalization

Treatment can take place outside the hospital or at an inpatient facility. To be considered for outpatient therapy, patients need to be medically and psychiatrically stable, have symptoms under control and not require daily medical monitoring.

The choice of residential care or hospitalization depends on how stable the patient is medically and from a mental health perspective, if the patient needs intensive medical care and/or daily assessment. Hospitalization might be needed to treat severe weight loss that has resulted in malnutrition and other serious mental or physical health complications, such as heart disorders, serious depression and suicidal thoughts or behaviors.

What are the complications of treating anorexia nervosa?

The most serious complication of treating anorexia is a condition called refeeding syndrome. This life-threatening condition can occur when a seriously malnourished person begins to receive nutrition again. Basically, the body cannot properly restart the metabolism process.

Patients experiencing refeeding syndrome can develop:

  • Whole body swelling (edema)
  • Heart and/or lung failure
  • Gastrointestinal problems
  • Extensive muscle weakness
  • Delirium
  • Death

Abnormal laboratory signs include low phosphate levels (hypophosphatemia), low blood sugar levels, (hypoglycemia), low potassium level (hypokalemia), low magnesium level (hypomagnesemia), and low sodium level (hyponatremia).

Patients who have one or more of the following risk factors for developing refeeding syndrome may need to be treated in the hospital:

  • Are severely malnourished (< 70 percent median BMI in adolescents; BMI < 15 in adults)
  • Have had little or no calorie intake for more than 10 days
  • Have a history of refeeding syndrome
  • Have lost a lot of weight in a very short period of time (> 10 to 15 percent of total body mass within 3 to 6 months)
  • Drink significant amounts of alcohol
  • Have a history of misusing laxatives, diet pills, diuretics, or insulin (if diabetic)
  • Have abnormal electrolytes before starting refeeding

How is refeeding syndrome managed?

The current approach is to start patients on a diet of approximately 2000 to 2500 calories/day increasing by 250 calories per day if electrolytes are stable. The goal is to gain 0.2 kg/day (almost ½ pound/day) while in the hospital. After the hospital stay, the expectation for weight gain is slower, with goals of 1 to 2 pounds per week. During this phase, energy needs may increase dramatically, with many patients requiring 3,500 to 4,500 calories/day to restore heart, brain and bone. These high metabolic needs are particularly important in children and adolescents who are still growing and developing.

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